Easingwold Satellite Renal Unit

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first rated assessment for this service. This key question has been rated Good:

This meant people were protected from avoidable harm.

We assessed 8 quality statements for this key question.

Risks were not always assessed and managed for example in relation to medicines management, estate and out of date policies, however there were good processes in place to report and learn from patient safety incidents.

We found that the service had robust systems and processes in place to keep patients and staff safe. The environment was safe and clean, and the staff had the required qualifications, training and skills.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were robust systems in place for the reporting of incidents, and monitoring of health and safety through a structured audit programme. Staff saw incidents as an opportunity to learn and improve, and we saw this learning disseminated through meetings.

Staff understood about duty of candour and the need to be open, honest, and transparent with people when things went wrong with their care.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission process ensured all essential information about the patient was recorded to ensure their needs could be safely met. Staff could access trust records to obtain essential information such as monthly blood results.

Patients’ records were clear and complete and contained up to date care plans and medication information.

The service had clear processes in place for identifying and escalating when patients were unwell. This included using a recognised clinical scoring system for assessing patients and either contacting the physician from the trust or calling an ambulance depending on the outcome of the assessment.

We heard from staff how the service had established good relationships with NHS partners and could escalate concerns to consultants in a timely way. We saw acceptance criteria and criteria for identifying when patients were not suitable for dialysis on the unit with a process for how to act on this.

The service had a process in place for managing missed appointments, which included phoning the service user and if there was no response, working with emergency services to initiate well-being checks to ensure that the person was safe.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The clinic manager was the local safeguarding lead and had undertaken level 3 safeguarding training for adults and level 2 for children. All staff had completed mandatory safeguarding training for children and adults to level 2. The manager could access support from the trust safeguarding team should they need it.

All staff we spoke with understood their responsibility in relation to safeguarding as well as how to report safeguarding incidents. The telephone numbers of who to contact in the event of a safeguarding concern were easily accessible for all staff. Staff said they could access safeguarding information and policies on the electronic system if they needed confirmation about what actions to take.

The unit had strict rules about who could access the unit and discouraged children visiting unless they were accompanied by an adult, closely supervised and only visited for a short period of time.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

If there was a medical emergency on site, staff knew to phone 999 and wait for an ambulance to transfer the patient to the local hospital. However, there was no standard operating procedure in place for staff to follow. Staff had been trained in immediate life support (ILS) which they would carry out until ambulance support arrived. Staff told us they understood what they had to do and were supported afterwards by colleagues and leaders. We discussed an incident where a patient had deteriorated which demonstrated that staff had taken decisive action.

Clinical risk was managed through regular multidisciplinary team meetings (MDT) between local consultants at the NHS trust and the provider. The service discussed and documented risks to patients in care plans.

We heard how staff worked with patients who chose to shorten treatment times, informing them of the potential risks and offering alternatives when possible. The service also demonstrated a robust system for following up patients who did not attend for their appointments. If appointments were missed, staff also attempted to provide alternative appointments that were convenient to patients to ensure continuity of treatment.

Risk assessments were carried out and reviewed regularly for each patient. These included but were not limited to: assessing moving and handling requirements; risk of falls; risk of needle dislodgement; and frailty.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Easingwold dialysis unit was based in part of a care home. Half of the building was unused and locked down, the other half housed the dialysis unit. The used portion had been adapted into chair spaces, offices and medicines storage and this was where dialysis was delivered.

We were concerned about the security of some areas of the building. The doorway into the abandoned section of the building was not locked or secured and we were able to enter the area easily. We also found other doors to restricted areas either had no locks or nonfunctioning locks. We highlighted these to the clinic manager who told us she had requested action through a formal reporting procedure to the estates team a number of times over an extended period, but nothing had happened. This was a breach of Regulation 15.

We reviewed the risk that was recorded on the Risk Register in January 2025. It recorded a number of risks including break in and arson. It had a risk level of 16 which was classed as severe.

We reviewed the clinical areas in the unit and identified one individual chair space in a separate room off the corridor. Once the room was filled with the therapy chair and dialysis machine there was little room for movement. We were concerned that in the case of an emergency there would be no room for movement or additional equipment such as for resuscitation or maintenance of life. We asked the provider if there was a risk assessment for the room which they provided. This showed a current risk of 15 (high) which meant an immediate response was required. The room remained in use, but the future plan was to decommission when capacity allowed this. This was a breach of Regulation 15.

We reviewed the resuscitation equipment held on site and found this was not a standard resuscitation trolley. The trolley was a small metal trolley with limited equipment. We were concerned about the lack of equipment and asked to see a risk assessment for the trolley. The unit told us there was no risk assessment but that the trolley had previously been reviewed by the critical care outreach team who did not identify any concerns. The trolley was further due for review in June 2026 after our inspection.

We identified that the unit did not have an emergency buzzer system in place. Patients were given a small metal desk bell to press if they needed help. We had concerns that this was not an effective call bell system and could put patients at risk of harm as we were not assured staff could hear these bells whilst carrying out duties with other patients. This was a breach of Regulation 15.

We spoke with the water engineer of the unit. They were able to describe the processes for maintaining clean water supply to the unit, how the water was extensively tested to make sure it was appropriate for dialysis, actions to take if problems were identified and how dialysis equipment was tested, maintained and repaired. We were assured that there were robust processes in place to keep patients safe.

The service had clear guidance on the criteria for replacement of equipment, with a replacement schedule in place to ensure that equipment always supported the delivery of safe treatment.

All equipment we reviewed was stored and managed safely. Stock items were stored appropriately, with effective housekeeping policies and processes. This included the control of substances hazardous to health (COSHH).

We saw evidence of clear processes in place for the treatment and storage of blood samples prior to being collected.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had robust recruitment processes in place to ensure that staff were appropriately qualified, checked and vetted and we saw evidence in staff files that these processes were followed.

There were sufficient staff deployed to meet the needs of patients.

All staff had the necessary training and skills that were required for the role. Training was role specific across the service. Clinical staff had completed all required training modules relevant to their roles, which included speciality-specific training such as a holistic approach to caring for frail patients in the renal setting, blood borne viruses in the renal setting, and more generic skills such as basic life support and prevention and management of falls. Non‑clinical staff, such as reception teams, also received training appropriate to their duties, including safeguarding, General Data Protection Regulation (GDPR) compliance, and records management.

Staff received a comprehensive induction and ongoing training and support, including end of year appraisals. Staff explained how some of them had started as support workers and described how the unit had supported them to access further education including funding to access the Objective Structured Clinical Examination (OSCE), a practical assessment examination required to hold Nursing and Midwifery Council (NMC) registration in the United Kingdom.

There were no medical staff based at the unit. Staff told us doctors were easily accessible if there were any queries about patient wellbeing or needs. We were not concerned about this.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. There were policies and procedures for infection control and the service assessed and managed the risk of infection.

During our visit we observed cleaning of the treatment area between patient sessions. We observed good infection prevention and control practices during our visit. There were plenty of hand gel dispensers around the clinic, which were all functional. Staff wore personal protective equipment in line with regulations. Staff were observed to follow good hand hygiene practice. We observed staff using appropriate aseptic non touch technique to reduce the risk of infection spreading from staff to patients.

We also saw evidence of regular infection prevention and control audits, and regular hand hygiene audits, with evidence that any areas of non-compliance were promptly escalated. We looked at cleaning audits for the three months leading up to our inspection and identified that compliance had improved and there were now no issues.

There were suitable furnishings, which were easily cleaned between patients and were well-maintained. The areas we visited in the unit were visibly clean at the time of the inspection.

Processes were in place to screen and isolate patients who had been on holiday to high-risk destinations, and we saw evidence of this being done in patient records. All patients were screened for blood-borne viruses every three months. We also saw documented processes for assessing and managing patients who were unwell whilst attending dialysis.

Hazardous and clinical waste was disposed of safely and responsibly managed which included a programme of recycling to minimise the impact of generating too much waste in a service which had a high usage of consumables.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We visited areas where medicines were stored, including fluids used on dialysis and the resuscitation equipment. We looked at 5 patient care records and spoke with 2 nurses on the unit.

There were several areas where medicines and substances used on dialysis were stored. There was a lack of safe processes to ensure security and confidentiality in all storage areas. Temperature monitoring was only performed for medicines stored in fridges and not in any other storage areas, which was not compliant with trust policy. There were areas, such as the corridor where the resuscitation trolley was kept, that were exposed to high temperatures due to radiator use in the same area. This could risk medicines being exposed to temperature levels outside of the manufacturer’s recommendation for safe and continued use. This was a breach of Regulation 12.

Medicines were safely administered in accordance with treatment plans that had been created remotely by prescribers. However, prescribers did not always add frequencies for treatment administration on prescriptions for Venofer, a medicine used to replace iron during haemodialysis. This can risk people receiving doses of medicines that are no longer suitable. This was a breach of Regulation 12.

People received person-centred care when attending the Easingwold Dialysis Unit for their treatment.

Staff demonstrated advanced clinical knowledge to support people to receive their treatment comfortably. People who received haemodialysis for the first time were counselled on their treatment and potential side effects. Staff completed observation monitoring and prescription charting at each visit, making sure medicines were appropriately administered according to the prescription.

Staff had access to remote prescribing and pharmacy support. There was a process in place for ad-hoc prescription changes, using the electronic prescribing system. There was also good access to pre-labelled medicines to support people with take home prescriptions if needed.

Staff on this unit had achieved 100% compliance with medicines management and department specific training. This ensured that staff could support patients safely.